THE TECHNICAL ASSISTANCE COMMITTEE IN THE CASE OF · THE TECHNICAL ASSISTANCE COMMITTEE IN THE CASE OF BRIAN A. v. HASLAM SUPPLEMENT TO THE FEBRUARY 8, 2016 MONITORING REPORT April

THE TECHNICAL ASSISTANCE

COMMITTEE

IN THE CASE OF

BRIAN A. v. HASLAM

SUPPLEMENT TO THE

FEBRUARY 8, 2016 MONITORING REPORT

April 4, 2016

Case 3:00-cv-00445 Document 554-1 Filed 04/04/16 Page 2 of 48 PageID #: 15367

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TECHNICAL ASSISTANCE COMMITTEE:

Steven D. Cohen

Senior Fellow

Center for the Study of Social Policy

Washington, D.C

Judy Meltzer

Deputy Director

Center for the Study of Social Policy

Washington, D.C.

Andy Shookhoff

Attorney

Nashville, TN

Paul Vincent

Director

Child Welfare Policy and Practice Group

Montgomery, AL

TECHNICAL ASSISTANCE COMMITTEE STAFF:

Michelle Crowley

Jamie McClanahan

Kelly Whitfield


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Table of Contents

Introduction .................................................................................................................................1

VI.D. Requirements Related to the Administration of Psychotropic Medications ...............2

VI.H. Case Manager Contacts with Children ..........................................................................10

VII.B. Participation in Child and Family Team Meetings ......................................................13

VIII.C.1. Diligent Searches and Case Review Timelines .......................................................17

XVI.A.1. Permanency Outcome Measures ...........................................................................18

Child Death Review (CDR) Process ........................................................................................24

TFACTS Update ...................................................................................................................28

APPENDICES

VII.B

VII.C.1

XVI.A

Caseload and Supervisory Workload Data


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INTRODUCTION

This Supplemental Report contains additional information which the Technical Assistance

Committee (TAC) has provided to the parties on a number of provisions covered in the February

2016 Monitoring Report to help inform the “maintenance discussions.”


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VI.D Requirements Related to the Administration of Psychotropic Medications

The overall goal of the requirements of Section VI.D of the Settlement Agreement is to ensure

that psychotropic medications are being responsibly prescribed and administered to treat

appropriately diagnosed mental health conditions in accordance with professional medical

standards, including the requirements of informed consent.

At the request of the parties, the TAC has been asked to indicate the level of confidence that it

has in the processes in place to ensure that psychotropic medications are being appropriately

prescribed for children in DCS custody and that informed consent is obtained before any child in

DCS custody is administered psychotropic medications. The TAC has also been asked to

provide some further discussion of the findings of the targeted review regarding documentation

of informed consent for children prescribed medications after they entered DCS custody.

A. The Recommendations of the American Academy of Child and Adolescent Psychiatry as a

Frame of Reference

In assessing the Department’s performance related to Section VI.D, the TAC has used as a frame

of reference the recently published best practice recommendations of the American Academy of

Child and Adolescent Psychiatry (AACAP).1 Ten of the AACAP recommendations

(recommendations eight through 17) are specifically relevant to psychotropic medication

monitoring and oversight responsibilities of child welfare agencies.2 The TAC therefore begins

this supplemental discussion with a review of those 10 recommendations and a brief summary of

the extent to which the Department’s approach to medication monitoring and oversight is

consistent with each recommendation.

8. Non-physician professionals working with youth should have knowledge of the guidelines in

AACAP publications and other relevant resource documents relevant to the use of psychotropic

medication with youth. As discussed in previous monitoring reports, the Department has

developed and broadly distributed best practice guidelines, policies, and forms, provided relevant

training to DCS staff, private provider staff, foster parents, and mental health agency staff, and

has provided ongoing outreach and consultation services through both its own DCS staff (DCS

health unit nurses, regional mental health consultants, Psychology Director, and Medical

Director) and through the Centers of Excellence.

9. Mental health agencies, child welfare, Medicaid agencies, and managed care organizations

should collaborate to create systems to monitor, review, and inform practice patterns with

psychotropic medications. This recommendation specifically refers to “infrastructure elements”

including “the capacity to share data; common practice expectations; common monitoring

standards; methods for data review; identification of red flag criteria triggering external reviews;

criteria for prior authorization; and methods for timely feedback to prescribers.” As discussed in

1 AACAP, Recommendations about the Use of Psychotropic Medications for Children and Adolescents Involved in

Child-Serving Systems (hereinafter referred to as the “AACAP Recommendations”) (2015). 2 AACAP Recommendations at pp. 2-3, 29-32.


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the February 2016 Monitoring Report, the Department of Children’s Services, with additional

support from the Vanderbilt Center of Excellence, has worked with TennCare (the state

Medicaid agency) and Magellan (the TennCare pharmacy benefits manager) to be able to access

and analyze pharmacy claims data in monitoring and overseeing the use of psychotropic

medications for children in DCS custody. The “red flag” criteria that the Department has long

used as triggers for special review by the Medical Director are included among the “red flag”

criteria that TennCare uses in its oversight of prescription practices and its criteria for prior

authorization (discussed in more detail below). The Department’s practice expectations,

reflected in the Department’s guidelines and policies, are consistent with TennCare policy; and

those expectations are reinforced by the guidelines and monitoring standards used by TennCare

Select in its oversight activities of prescribers.

10. State and county agencies serving children in foster care should use the Best Principle

Guideline in the 2005 AACAP Position Statement as the framework for developing formal

monitoring and oversight programs. The guideline calls for the agency to develop, in

consultation with child and adolescent psychiatrists: (1) policies and procedures to guide the

psychotropic medication management of youth in state custody and (2) effective oversight

procedures. The Department’s policies and practice guidelines were developed through a year-

long process that involved extensive consultation with state and national experts in child and

adolescent psychiatry; and those policies and practice guidelines have been reviewed and refined

periodically, always in consultation with leading experts in the field. The Department’s

oversight processes have also been designed in consultation with national and state experts in the

field of child psychiatry and pharmacology. The guideline also contemplates the development of

a “consultation program administered by child and adolescent psychiatrists,” a function served

by the Centers of Excellence.3

11. Consultation programs should involve child and adolescent psychiatrists, who can offer

technical assistance, second opinions and case review when indicated. This particular

recommendation was motivated by the increase in psychotropic medication prescribing by

primary care physicians for children and adolescents. Through the Centers of Excellence, the

Department has ensured that technical assistance, second opinions and case review services are

available throughout the state, to provide consulting support to non-psychiatric physicians, and to

DCS and private provider staff working with children who have mental health needs. The

Centers of Excellence provide the range of consultation services, from chart reviews, to

telephone conversations, to face-to-face assessments called for by the guideline.

12. Monitoring methods should entail a combination of approaches that includes review of

aggregate data on prescribing patterns, chart audits, and tracking of specific red flag markers.

As described further below, both the Department and TennCare use aggregate data, record

reviews, and tracking of red flag markers in monitoring psychotropic medication use.

3 The guideline also includes “development of a website to create ready access for clinicians, foster parents, and

other caregivers to relevant policies and procedures, specific forms, educational information, data and links.” The

DCS website, which is accessible to those identified groups, provides access to all of the relevant DCS policies,

procedures and documents. In addition, http://www.kidcentraltn.gov/, supported by DCS and other child-serving

agencies, provides a host of relevant information, links and resources.


http://www.kidcentraltn.gov/

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13. Child and adolescent psychiatrists should participate in the development of monitoring and

oversight standards in their state and community, and involved systems should actively support

their involvement. This recommendation encompasses the recommendation of the 2005

guideline discussed above, and includes monitoring and oversight responsibilities beyond those

of the child welfare agency.

14. Psychotropic medication monitoring and oversight efforts should involve ongoing

collaboration among state and county agencies as well as managed care organizations. As

discussed above, the Department’s ongoing collaboration with TennCare, TennCare Select, and

the Vanderbilt Centers of Excellence exemplifies the efforts called for by this recommendation.

15. Systemic oversight of psychotropic medication prescribing should be pursued in a collegial

manner that promotes the use of evidence informed practice. The collegial approach to system

oversight has long been embraced by those who have served as the Department’s Medical

Director over the years and continues today, from the ongoing outreach work of the regional

health unit nurses to build good working relationships with mental health providers and primary

care physician prescribers in the regions, to the work of the Centers of Excellence in providing

peer consultation.

16. Systems for medication review and for the approval or denial of psychotropic medication

requests should be streamlined and efficient, to avoid unnecessary treatment delay or provider

burden. This recommendation acknowledges the importance of ensuring that oversight

mechanisms do not interfere with the need to get children and adolescents “the pharmacological

treatment they need in a timely manner.” As discussed further below, the Department’s

oversight approach, including its approach to informed consent, has been implemented in a

balanced way that promotes best practice, including parent engagement, without placing undue

burdens on prescribers or unnecessarily delaying treatment.

17. All stakeholders and child-serving systems responsible for youth with complex mental health

needs should advocate for increased availability of evidence-based psychosocial interventions by

qualified staff. This final AACAP recommendation related to oversight and monitoring of

psychotropic medications emphasizes that youth with severe trauma or other complex behavioral

health needs should have access to effective psychosocial interventions, not just psychotropic

medication. In keeping with this recommendation, the Department’s review processes, from the

reviews conducted by the health unit nurses and regional mental health consultants to those

provided by the Centers of Excellence, evaluate prescribing practices in the context of the child’s

overall treatment.

B. The Three Levels of Medication Oversight

The Department currently relies on three levels of oversight to ensure that psychotropic

medications are appropriately prescribed.

The first level of oversight is that provided by the case managers, who have received the training

for non-physician professionals discussed above, and who are regularly monitoring the well-


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being of the children on their caseloads. These cases managers are supported by both the

regional health unit nurses and the regional mental health consultants, and they have access, both

directly and through the regional nurses and mental health consultants, to additional consultation

services from the Centers of Excellence. This first level of oversight allows questions and

concerns about mental health issues, including medication issues, to be raised and addressed.

There are a number of quality assurance processes in place to ensure that this first level of

oversight is ensuring appropriate medication practice. This includes case file reviews focused on

documentation (including regularly conducted Case Process Reviews and Program

Accountability Reviews (PAR), as well as the special, targeted reviews discussed in the February

2016 Monitoring Report). This also includes the Quality Service Reviews which assess, among

other things, emotional and behavioral well-being, and includes specific inquiry, for children

taking psychotropic medications, as to whether the effectiveness of the medication is being

monitored regularly.

The quality assurance activities at this first level of oversight also include the monitoring that the

health unit nurses do of “red flag” prescriptions and the ongoing work that they do with

prescribers, both proactively to ensure that they are up-to-date on DCS policy related to

psychotropic medications and in response to situations in which a prescriber’s performance fell

short of policy expectations.

The second level of oversight is that provided by the Centers of Excellence, both through the

technical assistance and case consultation they provide in specific cases, which includes review

of the appropriateness of medications in specific cases, but also through their review and analysis

of aggregate data to identify and respond to potentially problematic prescribing practices.

The third level of oversight is that provided by TennCare, Magellan (the TennCare pharmacy

benefits manager), and TennCare Select (the managed care provider for children in state

custody).

TennCare, through Magellan, has implemented three levels of point-of-sale controls that help

ensure responsible prescribing behavior: prior approval requirements; Prospective Drug

Utilization Review (PDUR); and Retrospective Drug Utilization Review (RDUR). Prior

authorization is required for prescriptions of specific psychotropic medications with higher risk

profiles. PDUR uses TennCare’s electronic monitoring system to screen prescription drug

claims to identify problems such as therapeutic duplication, drug-disease contraindications,

incorrect dosage or duration of treatment, drug allergy, and clinical misuse or abuse. RDUR

involves ongoing and periodic examination of claims data to identify patterns of fraud, abuse,

gross overuse, or medically unnecessary care and implements corrective action when needed.

The results of this review are used by TennCare to inform policy development and provider

education and to improve point-of-sale controls.

TennCare Select conducts regular audits of clinicians’ patient files to ensure that statutory and

regulatory Medicaid requirements are met, including, among other things, that there is an

appropriate diagnosis and treatment plan documented to support any psychotropic medication


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prescribed and that there is documentation of informed consent prior to commencement of any

treatment (including prescription of psychotropic medications).

Through these three levels of oversight, Tennessee has implemented a system that is well-

designed to promote appropriate mental health treatment of children in DCS custody, including

appropriate use of psychotropic medication.

C. The Informed Consent Requirements of Section VI.D

Section VI. D of the Settlement Agreement requires that “when possible, parental consent shall

be obtained for the use of medically necessary psychotropic medication,” that if a parent is

unavailable “the regional health unit nurse shall review and consent,” and that regional nurses

shall ensure “that each of their consents is appropriately recorded.”

While many child welfare systems have opted for the ease and administrative convenience of

simply authorizing case managers to provide informed consent, Tennessee, as reflected in the

Settlement Agreement, has appropriately embraced what is considered best practice: that parents

and older children should be actively engaged in the informed consent process, that only when

parents are unavailable and children are not old enough to consent for themselves, should state

agency staff be authorized to provide informed consent, and that only state agency staff with

relevant mental health expertise should have that authority. As discussed in the February 2016

Monitoring Report, the TAC’s review of 85 medications for which informed consent was

documented, found that informed consent was given by the parent or other guardian for 32 (38%)

of those medications and informed consent was given by the youth (age 16 or older) for 22

(26%). For 31 (36%) medications, consent was given by the health unit nurse, and in the vast

majority of those cases reviewers found documentation that the parents were unavailable despite

efforts made to engage them.

The priority that the Department places on trying to engage the parents in the informed consent

process adds a level of complexity to the informed consent process. Ordinarily, when a child

comes to a prescriber’s office, the child is accompanied by the child’s parent—the person who

has the authority and responsibility for giving informed consent. With children in DCS custody,

the child is ordinarily accompanied by a foster parent or case manager who does not have that

authority and responsibility. Sometimes the parent will be available to attend the appointment or

be available by phone, but sometimes the informed consent conversation with the parent (or the

conversation with the health unit nurse if the parent is unavailable) will not take place until after

the child’s appointment. The Department fully expects that psychotropic medication not be

administered unless informed consent has been obtained, but the Department recognizes that in

some cases the informed consent process will not be completed until after the appointment.

It is, of course, the responsibility of the prescribing physician to obtain informed consent from

the person authorized to give it—in the case of children in DCS custody, the parent, youth age 16

or older, or health unit nurse—and to document informed consent in the prescriber’s patient files,

whether through case notes, a signed form, or a check box. Once that consent has been obtained

by the provider, the Department, as part of its own oversight processes, seeks to have prescribers


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furnish separate documentation confirming for the Department that informed consent has been

obtained, using either the Department’s own informed consent form or a form with comparable

information. As part of assuring that informed consent has been obtained before medication is

administered, the Department policy requires that the child’s file (the TFACTS file for children

in DCS placements and the private provider file for those children in private provider

placements) has documentation of informed consent for every psychotropic medication that the

child is currently taking.

As discussed in the February 2016 Monitoring Report, the Department generally finds that once

prescribers understand the Department’s need for this separate documentation, they are generally

good about providing it. However, with children coming in and out of custody, with children in

custody moving and changing placements and prescribers, and with the natural turnover in

prescribers, there is a certain amount of slippage that occurs, resulting in delay in receiving

documentation in some cases, and failure to receive documentation in others.4 It is also not

unexpected that, when balancing the competing demands on their time, prescribers might

reasonably place a higher priority on the maintenance of timely documentation that TennCare

requires for the prescriber’s patient files and for billing, than on the secondary documentation

that the Department of Children’s Services needs for its files.

D. PAR Reviews

As discussed in the February 2016 Monitoring Report, the Program Accountability Reviews

(PAR) include, as part of the case reviews, a determination of whether there is an informed

consent form in the child’s agency case file for every psychotropic medication that the child is

taking and whether the consent form was signed prior to the administration of the medication.

The PAR reviewers compare prescription dates with medication administration logs and

informed consent documentation maintained by the private providers. A negative PAR finding is

made if there is insufficient documentation that informed consent was given prior to the

administration of the medication; in addition, a negative finding is made if there was an

unreasonable delay between the issuance of the prescription and the administration of the

medication because of a delay in obtaining documentation of informed consent.

For the 2014-15 PAR reviews, a total of 155 files were reviewed for documentation of informed

consent, and 140 (90%) of those files had the required timely documentation for every

psychotropic medication that the child was taking. This is consistent with PAR findings from

previous years: 88% (77/88) in 2011-12; 93% (150/162) in 2012-13; and 92% (132/144) in

2013-14).

Whenever PAR makes a finding that a child’s agency case file did not have a signed informed

consent form for one or more medications that the child was taking, PAR requires as a corrective

action that the agency either obtain a copy of the informed consent form from the prescriber or

4 The Department on occasion finds that a prescriber mistakenly obtains informed consent from someone the

prescriber believed had authority to grant it, but in fact does not. The Department therefore does outreach to

prescribers to make sure they understand that if a child is in DCS custody only the parent, the youth (if age 16 or

older), or the health unit nurse can give informed consent for psychotropic medications.


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other source (if the prescriber or other source has an executed form) or that the agency obtain a

new informed consent form, signed by the parent, youth age 16 or older, or regional health unit

nurse, as appropriate.

E. The Results of the TAC’s Targeted Review

The TAC’s targeted review looked for two kinds of documentation related to informed consent.

For those psychotropic medications that the child was already taking when the child entered care,

the TAC looked for documentation of approval of continued administration of those

medications.5 For those psychotropic medications that were newly prescribed after the child

entered DCS custody, the TAC looked for timely secondary documentation that informed

consent had been obtained. Applying the general requirement that case file documentation

should occur within 30 days of the date of the activity being recorded, the TAC considered this

secondary documentation to be timely if the documentation was dated within 30 days of the date

of the prescription of the medication.

For those 38 children (a total of 78 medications) in the targeted review sample who were taking

previously prescribed medications when they entered custody, the TAC found documentation of

approval for continued administration of those medications for 37 of the 38 children (97%), and

77 of the 78 (99%) prescribed medications.

For the 46 children (a total of 105 medications) in the targeted review sample who were

prescribed at least one psychotropic medication after entering custody, the TAC found

documentation of consent within 30 days of the prescription date for 76 medications (72%), and

for 30 of the 46 children (65%), the TAC found documentation of timely consent for all

medications prescribed.

The TAC did some follow-up on the 16 children for whom documentation was either not timely

or was not found for one or more newly prescribed medications (a total of 29 medications). The

following is a brief description of the nature of the insufficiency of the documentation in those

16 cases.

For five of these children (accounting for a total of eight medications for which

documentation of consent was not found), upon follow-up the Department found no

evidence that the child had actually taken the medication while in DCS custody.

For four other children (accounting for a total of six medications for which

documentation of consent was not found), consent was documented during the period

covered by the review, but either the documentation was not within 30 days or the

reviewer was unable to determine the timeliness of the secondary documentation because

the reviewer could not determine the medication start date.

5 While informed consent is required when a medication is initially prescribed, a new informed consent is generally

not required for the continuation of the medication. The Department’s requirement that there be “approval” for the

administration of medication that a child is already taking when the child enters custody is something beyond what

the medical profession’s “informed consent” process requires.


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In another case, a combination of these two factors account for all four medications for

which documentation of consent was not found. There is a consent form signed by a

legal guardian, but with no date, for three of four of the medications, and for the other

medication, upon follow-up the Department found no evidence that the child had actually

taken the medication.

For an additional three youth (prescribed a total of eight medications, three of which

lacked secondary documentation of informed consent), it appeared that for each child, the

medication for which timely documentation was lacking had been prescribed during a

short period of psychiatric hospitalization.

There was one additional youth (four medications) who appears to have refused and

never took three medications, but who took the fourth medication for a few weeks before

refusing it because of the taste. Documentation of consent was not found for this last

medication.

In the remaining two cases (involving a total of five medications, three of which lacked

documentation of informed consent), one of the medications for which documentation

was missing had been discontinued by the time it came to the attention of the health unit

nurse, and therefore no secondary documentation was entered in the file; and in the other,

secondary documentation was entered, but this occurred subsequent to the period covered

by the review.

The TAC found the results of this follow-up to be reassuring.

If one excludes from the review results those medications that were prescribed but never taken

(and for which informed consent was therefore not required or, perhaps to put it another way,

the right to refuse to consent was exercised), then 35 (76%) of the 46 children reviewed had

timely documentation of informed consent for every medication they were prescribed.

If one were also to include in the review results, all prescriptions for which the TAC found

documentation of informed consent, including those cases in which the consent was

documented more than 30 days after the date of the prescription (and including those cases in

which, because of a missing date, the TAC was unable to determine time between the date of

the prescription and the date of documentation), then 41 (89%) of the 46 children had

documentation of informed consent for every medication they were prescribed; and for 88

(95%) of the 93 medications that were both prescribed and taken, there was documentation of

informed consent.

The Department, of course, needs to continue to work with the prescribers to ensure that they

are providing documentation of informed consent in a timely manner and that the

documentation includes the date on which the informed consent was obtained if different than


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the date that the form was signed or submitted.6 However, the delays and lapses in

documentation identified in the TAC’s targeted review do not undermine the TAC’s overall

confidence in the Department’s oversight and monitoring of psychotropic medication use. The

TAC is satisfied that through the processes described above, the Department is meeting its

responsibilities under Section VI.D.

6 Toward this end, the Department, in consultation with the TAC and with additional guidance from a highly

respected expert consultant, is working to develop a follow-up process in connection with its Case Process Review

to specifically address timeliness of informed consent. The Department expects to be able to use the information

generated by the Case Process Review to further refine the informed consent documentation process.


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VI.H Case Manager Contacts with Children

As discussed in the February 2016 Monitoring Report, the TAC considers the primary and most

important components of the VI.H requirements to be the provisions related to the frequency of

face-to-face visits by case managers with children on their caseload, provisions which have

already been designated “maintenance” based on data presented in a prior monitoring report.7

The February 2016 Monitoring Report presented data on the two remaining elements of Section

VI.H: (1) that the case manager spend time with the child outside the presence of the caretaker

(“OPC time”) during each required face-to-face contact; and (2) that in cases managed by private

providers, there be joint a DCS-private provider case manager face-to-face contact with the child

and the resource parent or other caretaker at least once every three months.

However, the targeted review that the TAC conducted to generate the data presented in the

February report was not designed to look specifically at OPC time spent with children during

their first two months that a child is in custody, a period during which the Settlement Agreement

contemplates more frequent face-to-face contacts (a total of six), rather than the twice a month

visits required after the first two months. To address this oversight, the TAC has conducted a

supplemental targeted review.

The review was of a sample of 59 children, stratified by region and drawn from the 145 children

who entered custody during the second half of September 2015 (between the 16th

and the 30th

)

according to the October 5, 2015 Mega Report and who remained in custody for at least two

months.8

Table 6.1 presents the number and percentage of face-to-face contacts documented by DCS, and

if applicable, the private provider case manager during the first two months in custody, without

regard for documentation of OPC time. In 93% (55) of the 59 cases, the number of face-to-face

contacts met or exceeded the requirement of six face-to-face visits during the first two months in

custody.

7 This included maintenance on the provisions specifying the required frequency of visits at the child’s placement.

8 This sample size provides a confidence level of 95% and a confidence interval of plus/minus 10.


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Table 6.1: Face-to-Face Contacts by the DCS and/or Private Provider Case Manager during the First Two Months in Custody

Number of Visits with Documented OPC Time

Number of Cases Percentage of Cases

11+ 36 61%

6-10 19 32%

3-5 3 5%

2 0 0%

1 1 2%

0 0 0%

TOTAL 59 100% Source: March 2016 review of OPC time during the first two months in custody.

Table 6.2 presents the number and percentage of face-to-face contacts presented in Table 6.1

above for which OPC time was documented.9 In 49% (29) of the 59 cases, the child received at

least six face-to-face contacts during the first two months in custody for which OPC time was

documented. In an additional 21 cases (36%), the child had documented OPC time for between

three and five contacts.

Table 6.2: OPC Time Documented by the DCS and/or Provider Case Manager during the First Two Months in Custody

Number of Visits with Documented OPC Time

Number of Cases Percentage of Cases

11+ 9 15%

6-10 20 34%

3-5 21 36%

2 7 12%

1 1 2%

0 1 2%

TOTAL 59 100% Source: March 2016 review of OPC time during the first two months in custody.

For reasons that the TAC has alluded to in the February 2016 Monitoring Report and discussed

at greater length with the parties, case managers understand from their training and from their

ongoing supervision that a routine element of a face-to-face visit is to spend OPC time with a

child. They are therefore understandably not motivated to separately document OPC time in

their case narrative unless there is something notable about it,10

and while OPC time can

9 The reviewers determined OPC time using the guidelines discussed in the February 2015 Monitoring Report at

pages 33-34. 10

The importance of OPC time has long been a part of the DCS training on “quality visitation” as well as an

emphasis of routine case supervision.


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sometimes reasonably be inferred from the documentation of the location or context of the visit,

this is simply one aspect of case practice for which case file review results will inevitably

understate system performance. The TAC therefore is well satisfied with the level of

performance documented by this review: that in 85% of the cases in this supplemental review,

reviewers were able to find documentation of OPC time in three or more visits (at least half of

the six visits required in the first two months); and that in 96% of the cases, at least two visits

during those first two months.

The TAC is also reassured by other data reflecting that the overall purposes that the OPC visit

requirements are intended to serve are in fact being met. The OPC visit requirements of Section

VI.H are intended to ensure that the child has an opportunity to voice concerns and desires on his

or her own behalf to the case manager so that those concerns and desires are taken into account.

In all cases, OPC time serves to promote effective engagement; in cases in which the concerns or

desires relate to potentially or actually harmful circumstances, the OPC time helps ensure safety.

The Department’s performance on the “Voice and Choice” Quality Service Review (QSR)

indicator suggests that children generally do feel that their voices are being heard by their case

managers and that their concerns and desires are taken into account. The statewide Voice and

Choice scores for the child for the two years for which that indicator has been included in the

QSR were acceptable in 87% of the cases in the 2013-14 QSR and in 88% of the cases in the

2014-15 QSR.

The Department’s performance on the QSR Safety indicator, as well as other data related to the

safety of children in placement regularly reported in the TAC’s monitoring reports, reflects that

safety related oversight activities, including case manager visits with children in their placements

and OPC time with children during visits, are occurring sufficiently to ensure the safety of

children in placement.


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VII.B Participation in Child and Family Team Meetings

As discussed in the February 2016 Monitoring Report, the Department’s General Counsel, with

the assistance of the Administrative Office of the Courts (AOC), contacted every attorney who

accepts appointments in dependency neglect cases, affirming the importance of attorney and

guardian ad litem (GAL) participation in Child and Family Team Meetings (CFTMs), and

inviting attorneys to contact him to share any “issues and/or suggestions on how DCS can assist

you in attending CFTMs.” The TAC has been asked to provide some additional detail on the

responses received and the work being done with regional staff based on those responses.

The TAC has also been asked to provide some additional information on participation of parents

and other family members in CFTMs by indicating the extent to which either a parent or relative

caregiver was present at the Placement Stability or Discharge Planning CFTMs subject to the

CFTM review. That information is presented in Appendix VII.B.

A. Responses to the General Counsel’s Letter

The letter from the DCS General Counsel was distributed by the Administrative Office of the

Courts by e-mail to the approximately 2,000 attorneys across the state.11

The DCS General

Counsel received 38 responses to this communication. According to the data compiled by the

General Counsel:

Fourteen of the attorneys who responded did not report any problems with the process by

which CFTMs were scheduled: five commented positively about their experiences with

the notice and CFTM scheduling process, and nine others had no specific comments

about the notice and scheduling process but shared other concerns or suggestions for

improvement, unrelated to CFTM scheduling.

The remaining 24 attorneys who responded identified challenges related to consistency of

advance notice to them by DCS of scheduled CFTMs. Most of these attorneys noted that

it is very difficult to coordinate schedules among all team members and that lack of

timely notice is most common with newer workers or in instances in which the timeline

requirements for CFTM completion leave insufficient flexibility for selecting meeting

dates that match their schedules.

B. CFTM Scheduling Pilot Protocols

Almost half (18 of 38) of the responses came from attorneys practicing in either Davidson or

Shelby county. The most significant finding from attorney responses in those counties was that

attorneys felt that their schedules were not being considered in scheduling CFTMs. While the

Department is clear that the first priority in scheduling is availability and convenience for the

11

The AOC mailing list used included, but was not limited to, the attorneys who receive compensation from the

AOC for representing parents and children in neglect and abuse hearings.


15

family members and their supports, in response to the concerns raised by the responses from

these 18 GALs, the Department is piloting new CFTM scheduling protocols in Shelby and

Davidson counties. The new protocols instruct case managers to identify multiple potential dates

when families are available to meet and then to provide all of those dates to the team before

scheduling. The team is then given an opportunity to respond with their availability for each of

the provided dates, and the meeting is scheduled on the date most convenient for the largest

number of team members.

The regional staff overseeing the pilots have collected and compiled tracking data from the two

pilot sites to help the Department evaluate the impact of the new scheduling pilot project on

attendance at CFTMs by both GALs and Court Appointed Special Advocate (CASA) volunteers.

During the period from December 22, 2015 through March 9, 2016, there were 102 CFTMs

subject to the scheduling pilot project. GALs had been appointed in time to participate in the

scheduling process for 91 of those CFTMs. GALs responded to the scheduling notice for 54

CFTMs and GALs attended 46 CFTMS. During that same period, there were 21 CFTMs for

which CASAs had been appointed in time to be included in the scheduling process. CASAs

responded to the scheduling notice for 18 CFTMs and CASAs attended 14 CFTMs.

C. Regional General Counsel Letters to Attorneys on Court Appointment Lists

The data from the pilot projects reflect that even with notice and an opportunity for input into the

scheduling of the CFTM, GALs may not attend CFTMs as regularly as one would hope.

Nevertheless, to reaffirm and underscore the substance of the Deputy General Counsel’s letter,

the Department has asked the juvenile courts to provide to each attorney currently on the

guardian ad litem appointment lists, and to going forward to provide any attorney who is newly

added to the appointment lists, a letter from the regional general counsel. The letter furnished by

the Department includes the name, e-mail address, and phone number of the DCS legal team

serving the relevant county, as well as the address of the program staff office serving the county

and the main phone number of that office. The letter then states the following:

“If your case includes a child in foster care, you should expect to be invited to a couple of Child

& Family Team Meetings (CFTMs) within the first months and to additional CFTMs as the case

moves along to review progress, revise the permanency plan, and address specific issues as they

arise. We know that you may not be able to attend every meeting, but we do expect that you will

receive timely notice. If that is not happening, please contact me, a member of our legal team, or

the Regional Administrator, [RA] at [RA phone number].”

The Regional General Counsels (RGCs), in most cases with the assistance and cooperation of the

juvenile court and in some through direct mailing to those attorneys that the RGCs are aware

accept court appointments, have ensured that the vast majority of attorneys currently serving as

GALs have been provided this letter.


16

D. Relevant Quality Service Review Results Related to Teamwork and Coordination

As discussed in the February 2016 Monitoring Report, there are three Quality Service Review

(QSR) indicators, Voice and Choice for the Child and Family, Engagement, and Teamwork and

Coordination, which in combination, measure both the extent to which teams are being formed

with the right membership and the extent to which those members are actively involved in the

Child and Family Team process, including participation in CFTMs. The Voice and Choice for

the Child and Family and the Engagement indicators are specifically focused on active

involvement of the child and family in the CFT process and the QSR scores for those indicators,

in combination with the other data related to child and family participation presented in the

February 2016 Monitoring Report, demonstrate the Department’s strong performance.

The Teamwork and Coordination indicator measures team member participation more broadly,

and provides a relevant context for assessing levels of CFTM attendance by GALs and CASA

volunteers. As discussed above, the data generated by the scheduling pilot projects in the Shelby

and Davidson regions reflects that even with improved scheduling procedures, it is likely that

CFTM attendance rates by GALs and CASAs will continue to fall far short of the rates of

participation by older children and engaged parents and family members (whose schedules are

appropriately given priority by the Department). The QSR Teamwork and Coordination

indicator appropriately recognizes the realities of scheduling challenges that will make it difficult

for some team members to regularly attend CFTMs; cases can score acceptable for Teamwork

and Coordination even when team members cannot attend meetings, as long as team members,

through communication that occurs between meetings, have an opportunity to have input into the

decisions of the team.

While the Department appropriately continues to look for ways to increase the attendance of

GALs and CASA volunteers at CFTMs, as long as there is generally good communication,

teamwork and coordination among team members, including the GAL and CASA volunteer,

there is less reason for concern if the GAL or CASA is unable to attend a given CFTM.12

The

Department’s current QSR performance on Teamwork and Coordination is therefore reassuring.

As reflected in the figures presented in the February 2016 Monitoring Report, the percentage of

cases receiving an acceptable score for this indicator reflects substantial improvement over the

course of the last three review periods, from 53% in 2012-13, to 73% in 2013-14, and 82% in

2014-15. (As discussed in previous monitoring reports, acceptable system performance scores in

70% or more of the cases reviewed are considered indicative of a reasonably well-functioning

child welfare system.)

This level of QSR performance, combined with the actions that the Department has taken to

ensure that GALs and CASAs are receiving notice and to improve CFTM scheduling processes

in an effort to improve attendance, are sufficient to address the concerns that the TAC might

otherwise have had about the level of attendance of GALs and CASAs at CFTMs.

12

In fact, a number of those who commented positively in response to the General Counsel’s letter specifically

noted that when they are unable to attend CFTMs they may provide input by talking to the DCS worker in advance

of the CFTM, and they may follow up with the DCS worker after the CFTM.


17

Most importantly, in assessing the Department’s overall performance on the requirements of

Section VII.B as a whole, the QSR results on all three relevant indicators, combined with the

other data presented in the February 2016 Monitoring Report, provide ample support for bringing

this provision into maintenance.


18

VIII.C.1 Diligent Searches and Case Review Timelines

As referenced in the February 2016 Monitoring Report,13

“diligent search” has been added as a

case activity type option in the TFACTS case file, allowing case managers to more easily

document diligent search activities in their case recordings and facilitating tracking and reporting

related to diligent search. In response to the request of the parties, the TAC has included in

Appendix VIII.C.1 of this supplemental report, a screen shot of the drop down box in TFACTS

that the case managers now use to quickly indicate the specific category of diligent search

activity performed.

13

The data presented in the February 2016 Monitoring Report (in Figure 8.1 and related discussion) tracks the

percentage of children who had timely diligent search activity at three, six, nine, and twelve months after entrance

into custody. The review that the TAC monitoring staff conducted (also detailed in the February 2016 Monitoring

Report) looked at diligent search activity in the first 30 days in custody.


19

XVI.A.1 Permanency Outcome Measures

A. Section XVI.A.1 Timeliness of Permanency

The current Section XVI.A.1 permanency outcome measures track the federal Child and Family

Service Review (CFSR) measures which were in effect at the time the original Settlement

Agreement was entered. As discussed in the February 2016 Monitoring Report, the Federal

Government has since recognized that those measures were developed using a seriously flawed

methodology and could not reasonably be considered valid indicators of a state’s permanency

performance. The federal government has therefore abandoned those measures and adopted new

measures for assessing timeliness of permanency.

The parties and the TAC have agreed that it makes no sense to continue to measure timeliness of

permanency using an invalid measure that the Federal Government has abandoned. The parties

have therefore agreed that Section XVI.A.1 should be modified to include a measure that tracks

the current federal CFSR measure. The parties have also agreed that the Department’s

performance under the current federal CFSR measure, and further supported by the Chapin Hall

data presented in the February 2016 Monitoring Report, warrants a maintenance designation.

B. Sections XVI.A.3 and XVI.A.5 Number of Placements and Reentry into Placement

There are other Section XVI outcome measures, XVI.A.3 (number of placements) and XVI.A.5

(reentry into placement) which also no longer represent the most current methods for assessing

performance. Both of these provisions have been and remain in maintenance. However, the

TAC believes that it is important to acknowledge the shortcomings of these Section XVI

measures and provide supplemental analysis that draws on the more current methods for

measuring these two areas of system performance.

1. XVI.A.3 Number of Placements

Section XVI.A.3 of the Settlement Agreement contains two requirements related to the number

of placements:

At least 90% of children in care shall have had two or fewer placements within the

previous 12 months in custody, not including temporary breaks in placement for children

who run away or require hospitalization and return to the same placement.

At least 85% of children in care shall have had two or fewer placements within the

previous 24 months in custody, not including temporary breaks in placement for children

who run away or require hospitalization and return to the same placement

This approach to measuring performance related to number of placements falls short of more

sophisticated measures in several respects. First, the measures fail to account for length of stay


20

in care and its impact on risk for movement. Second, the measures fail to demonstrate actual

number of moves but rather compare children who experience more than two placements over a

period of time with those who do not. Finally, the measures fail to provide a sufficient level of

detail to allow systems to identify the likelihood that children will experience placement moves

at different intervals of their custodial episode.

In order to provide a more useful representation of the Department’s performance with regard to

this provision, the TAC considered additional sources of evidence. First, the TAC considered

the current federal measure for placement stability. This measure tracks placement stability for

children entering care in a 12-month period. It assesses total placement moves for children

entering care in a 12-month period per number of care days for those children. Specifically, the

measure asks:

Of all children who enter foster care in a 12-month period, what is the rate of placement

moves per day of foster care?

While this measure represents some improvement over the original Brian A. measure in that it

captures movement within the first year of placement, it fails to account for all children exposed

to the risk of experiencing placement moves, particularly those in care longer than 12 months.

Additionally, the sample for the federal measure includes children with delinquent adjudications,

meaning that the results are impacted by children in Tennessee’s system who are not members of

the Brian A. class.

Notwithstanding the limitations cited above, the TAC has examined Tennessee’s performance on

the federal measure for purposes of reporting on the Department’s performance related to

placement moves. The most current published results of the Child and Family Service Review

establish a national standard of 4.12 moves per 1,000 days in care, based upon performance for

federal fiscal year 2014. Tennessee’s observed performance on the measure for the period from

October 1, 2013 through September 30, 2014 reflected a rate of 5.31 moves per 1,000 days in

care. However, as previously described, this rate of movement includes the effect of children

committed to the Department as delinquent youth in addition to Brian A. class members, and as a

whole, young people committed as delinquent youth experience more placement changes than

class members.

In order to address the factors that prevent application of the federal measure to the Brian A.

class, the TAC also considered the more detailed analysis completed by Chapin Hall. The

analysis follows children admitted to care between 2010 and 2014. It relies on five entry cohorts

in order to maximize the number of children whose placement experiences contribute to the

analysis. Figure 16.1 shows unadjusted, actual number of moves per 100 days in care.14

The

data represent states in Chapin Hall’s multistate foster care data archive (FCDA), a collection of

placement records used to track the performance of 19 state foster care systems. Chapin Hall

14

The period measured for each cohort is from the date of admission through the end of 2014. The groups are

organized into cohorts based on the date of admission. Moves are counted for children in each cohort until the date

of discharge. There is no fixed observation period. The analysis deals with length of the observation window by

counting the moves per 100 days in care, so that the values will be larger and more easily interpreted in the figure (in

hundredths rather than in thousandths).


21

receives placement data from each contributing state, harmonizes the data so that the included

populations and data elements are as close to identical as the underlying data systems allow. In

the case of these analyses, because only Brian A. class children are included, the FCDA is the

only source of comparative, multistate data currently available.

Source: Chapin Hall’s Multistate Foster Care Data Archive.

The results show that Tennessee has an average rate of placement moves—that is, a rate of

placement that neither out-performs nor under-performs the multistate group as a whole.15

When

evaluating movement rates across each year separately, the results of this analysis are

confirmed—in no year did foster children in Tennessee move more often, on average, than

children from the other states as a whole. A table containing the numerical values from which

Figure 16.1 was created is attached as Appendix XVI.A.

2. XVI.A.5 Reentry into placement

The Settlement Agreement approach to measuring performance related to reentry into care also

suffers from critical methodological failings. Section XVI.A.5 requires that:

15

A number of states have an elevated rate of movement in the most recent year. This is an artifact of when moves

tend to occur. In general, movement rates are much more common in the first year of placement. In the chart that

shows movement rates by year and state, results for the more recent cohorts (e.g., 2013) are dominated by the fact

that the children in these cohorts are still in the early days of placement, to the extent they have not yet been

discharged.

0.00

0.10

0.20

0.30

0.40

0.50

0.60

Mo

ves

pe

r 1

00

day

s

State

Figure 16.1: Moves Per 100 Days in Care

2010 2011 2012 2013


22

No more than 5% of children who enter care shall reenter within 1 year after a previous

discharge.

The provision poorly defines the measure that should be applied, but the approach used for

reporting on this performance is the most reasonable interpretation of the language in the

Agreement. Reporting on this measure has used an exit cohort to determine what percentage of

children exiting custody in a 12-month period return to custody within the 12 months following

their discharge. This approach suffers from a number of flaws. First, as previously noted by the

TAC, the measure includes children who age out of custody, and thus can never reenter care.

Second, the measure relies on an exit cohort that does not account for length of stay. Therefore,

it is more difficult to draw conclusions about strength of performance because the sample of

children considered includes those in custody a very short time, as well as those with longer

lengths of stay. In addition, because the measure is based upon an exit cohort, it is more difficult

to understand what the data reflect about system performance. Children who entered care at

different times were impacted by different environmental circumstances, different iterations of

DCS practice, and legislative changes that affected their movement through the system.

A more valid, reliable approach to evaluating performance related to reentry relies on an entry

cohort16

and follows children who enter care and exit to reunification within a 12-month period.

The federal method for assessing performance related to reentry now uses this approach.

Specifically, the measure asks:

Of all children who enter foster care in a 12-month period who were discharged within 12

months to reunification, living with a relative, or guardianship, what percentage re-enter

foster care within 12 months of their discharge?

While the federal measure for this outcome is more methodologically sound than others

discussed, the TAC believes it still fails to precisely measure performance related to class

members. Because the federal measure accounts for all children in eligible placements,

Tennessee’s juvenile justice population skews the overall performance assessment and renders

the results inapplicable to measuring compliance with the Settlement Agreement. In other

words, the federal measure is instructive but not determinative of the Departments’ performance

with regard to Section XVI.A.5.

Notwithstanding the challenges of applying this federal measure to the Settlement Agreement

provision, the TAC, while acknowledging the limitations, considered the Department’s

performance on the federal measure for purposes of this reporting. The most current published

CFSR results for reentry establish a national standard of 8.3%. Tennessee’s observed

performance on the measure reflected a reentry rate of 9.1%.17

The 0.8% difference accounts for

eight children, meaning that Tennessee exceeded the national standard by only eight children

16

See Appendix, A Brief Orientation to the Data: Looking at Children in Foster Care from Three Different

Viewpoints, of the February 2016 Monitoring Report for a discussion of the appropriate uses of entry cohort, exit

cohort, and “point-in-time” measures. 17

See the “CFSR Round 3 Statewide Data Indicators Workbook,” available online at:

http://www.acf.hhs.gov/sites/default/files/cb/cfsr_stateperformanceworkbook.pdf


www.acf.hhs.gov/sites/default/files/cb/cfsr_stateperformanceworkbook.pdf

23

reentering care and as noted above, the Tennessee data includes the population of children who

are adjudicated as delinquent.

In order to address the factors that prevent application of the federal measure to the Brian A.

class, the TAC also considered the more detailed analysis completed by Chapin Hall. The

Chapin Hall data analysis measures reentry to care following a discharge to either reunification

or to a relative,18

provided the return to care happens within one year of discharge. The analysis

proceeded in much the same way as placement stability analysis discussed above; it again

follows children admitted to care between 2010 and 2014. Five entry cohorts are observed in

order to maximize the number of children whose placement experiences contribute to the

analysis, and the analysis controls for the year of entry. There are no other adjustments made to

the results presented in Figure 16.2.19


Figure 16.2 shows the results of the analysis, which compares Tennessee with the same states as

the previous analysis. Again, because only Brian A. class children are included, the FCDA is the

only source of comparative, multistate data currently available. The results presented are the

observed, unadjusted reentry rates. Again, these descriptive data indicate that Tennessee’s

reentry rate does not differ markedly from the average of all the states. Specifically, the average

rate in Tennessee (after taking the year of admission into account) is somewhat lower than the

18

As is the case with the federal measure, this includes discharge to guardianship. 19

The period measured for each cohort is from the date of admission through the end of 2014. The groups are

organized into cohorts based on the date of admission. The analysis follows children in each cohort until 12 months

after the discharge date or until reentry, whichever comes first.

0%

5%

10%

15%

20%

25%

Pe

rce

nta

ge R

ee

nte

red

State

Figure 16.2: Reentry within 12 Months after Permanency Exit

2010 2011 2012 2013 2014


24

overall average. When Chapin Hall tested this claim using a more advanced statistical model,

the results were affirmed. A table containing the numerical values from which Figure 16.2 was

created is attached as Appendix XVI.A.

It should be noted that measures like reentry also balance competing priorities. Agencies strive

to reunify children both quickly and sustainably. A very low reentry rate may reflect policies

that result in unnecessarily long stays in custody. Conversely, a very high reentry rate may

reflect policy decisions that lead to returning children quickly but in circumstances that are not

sustainable. A moderate rate of reentry, such as Tennessee’s, reflects, in the TAC’s view, an

appropriate, responsible balance of these interests.


25

Child Death Review (CDR) Process

As noted in previous monitoring reports, the TAC has found the Department’s Child Death

Review Process (CDR) to be well-designed and appropriately implemented. In the February

2016 Monitoring Report, the TAC reaffirmed, based upon ongoing observation and review of the

various stages of the CDR process, that the current protocol is being responsibly carried out, and

that timeline and reporting requirements are being met. The TAC has been asked to provide

some additional detail and context to supplement the discussion presented in the February 2016

Monitoring Report.

A. A Brief Recap of the Circumstances Giving Rise to the Development and Implementation of

the New Child Death Review Process

Prior to implementation of the new Child Death Review Process, the Department did not have

clear or well defined decision rules on what counted as a child death subject to Departmental

review (particularly with respect to children not in DCS custody at the time of death), who was

required to report child deaths, in what time frames and to whom and how that information was

to be shared and used by DCS for both immediate actions and review of systemic factors. The

former system for reporting relied on over 1,000 staff to enter information disparately into a low-

functioning TFACTS system that was difficult to use. This resulted in the lack of a reliable

system for the retrieval, aggregation, and reporting of data on child deaths.20

The Department

also lacked a defined or systematic process for qualifying deaths for a death review.

In response to these problems, the Department committed in April 2013 to comprehensively

revising its Child Death Review process. The revised process, developed with significant input

from Department leaders, Vanderbilt’s Center of Excellence, plaintiffs, and the TAC, was

implemented on August 28, 2013. Since implementation of the current process, the Department

has established clear decision rules for counting child deaths and near deaths. The Department

has also implemented multiple redundancies to ensure the accuracy of information, including:

a detailed front-end process (outlined in DCS Policy 20.27) for reporting child deaths and

near deaths to the Child Abuse Hotline for investigation, notifying regional and Central

Office leadership, and ensuring the safety of any other involved children;

20

Although the former system had the capacity to accurately track deaths of children in custody using the “death of

a child” exit type, the process for reviewing child deaths at that time relied on hand-counts of custody deaths rather

than the data available from TFACTS. For deaths of children not in DCS custody, because there were no clear or

well-defined rules about what qualified as a non-custody death for review, there was no guidance to offer field staff

about what specific information needed to be entered into TFACTS so that non-custody child deaths could be

aggregated (for example, one case manager may have assumed that entering the date of death for the child was

sufficient, while another may have assumed that entering an abuse death allegation was sufficient, and another case

manager may have entered a completely different piece of information related to the death). This, in combination

with a cumbersome and time-consuming process for entering death information in TFACTS at that time, resulted in

a system that contained various pieces of information regarding non-custody child deaths but lacked a way to

produce an accurate list of non-custody children who had died.


26

a well-functioning TFACTS system that captures child death and near death data in a

defined portal;

a centralized staff person overseeing the child death portal data; and

a manual redundancy whereby TFACTS data is matched against manual hand counts.

The new process has established clear decision rules that identify child deaths and near deaths

that qualify for the Child Death Review Process; increased transparency by creating a system to

publish child death and near death information on the DCS website; and created well-defined and

articulated policy that supports the documenting, recording, qualifying and public posting of

child death and near death information.

B. A Description of the Essential Elements of the Child Death Review Process that the TAC

Has Observed and Reviewed and Determined are Functioning Consistent with the Current

CDR Protocol

The following is a description of each of the essential elements of the Child Death Review

Process. The TAC has observed and reviewed each of the described elements and has found

them religiously adhered to and of uniformly high quality.21

The TAC has validated all of the

reports that both support and document the process. For calendar year 2015, through a

combination of reviewing and tracking individual cases and utilizing the validated aggregate

data, the TAC found that timelines were met in every case subject to the review process.

The current child death review process includes both a Central Office review and a “systems

analysis” review that occurs in the field. The Central Office review occurs within 30 days after a

child death or near death is recommended for review by the Office of Child Safety. The Central

Office review team identifies any immediate concerns and determines which cases need further

review with systems analysis. If recommended for systems analysis, the case receives a systemic

review within 90 days. This review includes staff debriefings and a systemic review by a

regional multidisciplinary team.

Staff debriefings are facilitated opportunities for staff involved in death or near death cases to

share, process, and learn. Debriefing opportunities typically include front-line staff and

supervisors, but may include other positions as needed. During debriefings, staff share and

process their experiences working the death or near death case and/or historical cases specific to

the child or family associated with the death or near death case. Debriefings explore critical

decisions and interactions throughout the Department’s history with the subject child or their

family (e.g., removal decisions, service provision, teamwork opportunities, record acquisition,

etc.) and create a safe environment for staff to identify opportunities for learning and

improvement. The debriefing information is provided to the regional systems analysis teams.

21

Through participation in many Central Office Child Death Reviews and review of minutes for all 2015 Central

Office Reviews, the TAC found no instance of a case warranting a regional review that was not referred. The TAC

was equally impressed with the quality of the regional reviews that TAC members and staff observed.


27

Regional systems analysis teams are comprised of representatives from different disciplines

within DCS (e.g., front-line staff, front-line supervisors, health representatives, and regional

leadership) and from partner agencies (e.g., law enforcement, Child Advocacy Centers (CACs)

and health providers). The team is supported to review the case using a systems analysis model.

The systems analysis model challenges team members to analyze cases to identify systemic

vulnerabilities (e.g., teamwork, staffing ratios, and service array) and identify any case specific

concerns.

The regional safety analyst facilitates both the debriefings and the systems analysis. Safety

analysts are child welfare experts trained to have human factors and system safety expertise.

Additionally, the safety nurses assist safety analysts. Safety nurses are nursing positions

dedicated to the child death review process to support the safety analyst to review any complex

medical information associated with death or near death cases.

In 2015, the Department reviewed a total of 123 child death or near death cases. Of those cases,

60 were submitted for Systems Analysis for a more robust evaluation. As part of the Systems

Analysis review process, 140 debriefings with staff were conducted. Each debriefing lasts a

minimum of one hour; therefore, at least 140 hours of discussion with front-line case managers

and supervisors contributed to the Department’s evaluation and analysis of practice through the

Child Death Review in 2015.

In addition to the direct benefits of an improved system for tracking, reporting, and reviewing

child deaths and near deaths, the Child Death Review Process is also a vehicle for identifying

and analyzing systems issues and generating improvements. Findings and recommendations

from reviews are provided monthly to the Safety Action Group, consisting of the Commissioner,

Deputy Commissioner of Child Health, Deputy Commissioner of Child Safety, Deputy

Commissioner of Juvenile Justice, Assistant Commissioner of Quality Control, General Counsel,

Assistant Commissioner of Finance and Budget, TAC, Director of Policy Continuous Quality

Improvement (CQI), and Director of Safety Analysis. This group reviews information generated

by the Child Death Review, as well as the Confidential Safety Reporting System and other CQI

activities, in order to develop and implement system improvements.

One example of an improvement initiated by the Safety Action Group is increased availability

of, and a streamlined process for procuring, safe sleep furniture for families when an unsafe

sleeping environment is identified. Through partnership with local health departments and

acquisition of a stock of resources for local offices, the Department has increased the timeliness

of providing safe sleep resources to families. These changes were prompted by the

understanding from the CDR process of the risks to child death posed by the lack of safe

sleeping practices for young children and challenges to obtaining safe sleep furniture for at risk

families.

Another initiative implemented through the Safety Action Group monthly review is an updated

standard for transportation and guidelines for how long and far staff can travel in prescribed time

frames. The policy provides for case managers to stay overnight after transporting children or

travel with a co-transporter if transportation of a child or travel back to the case manager’s home


28

will require the case manager to remain on the road after reaching the maximum number of work

hours.

The Safety Action Group also addressed recurring issues related to acquisition of medical

records. The Child Death Review identified challenges case managers faced in obtaining

medical records from various facilities. To address this, Safety Analysis and CQI worked with

the DCS Legal Division and the Forms Committee to create a request form that explains clearly

to medical providers the statutory authority pursuant to which the provider is permitted to

provide records to DCS. Prior to development of this request form, some providers were unclear

about what records the Department is entitled to obtain in the course of investigating abuse and

neglect. This led to inconsistent practice across the state related to obtaining medical records and

created challenges for conducting timely, complete investigations when facilities refused to

provide records to investigators. Now, case managers have a clear, consistent mechanism for

communicating to medical facilities the statutory grounds granting DCS access to certain

medical records.

As the final step in the process, as discussed in the February 2016 Monitoring Report, each

quarter the Director of Safety Analysis is required to submit to the Commissioner within 30 days

of the end of the quarter a report covering the reviews conducted during the quarter, including

demographic information for the cases reviewed and findings, recommendations, and

Department actions from the reviews. Each year, the Office of Child Health is required to

submit to the Commissioner during the first quarter of the following year a report covering the

reviews conducted during the year. The report is to include demographic information and cause

and manner of death/near death for each case as well as the findings, recommendations, and

Department actions from the Child Death Reviews.


29

TFACTS UPDATE

A. Introduction

Four years ago, two reports—an internal assessment commissioned by the Department of

Children’s Services22

and an external audit conducted by the Comptroller’s Office23

—identified

significant problems with TFACTS (Tennessee Family and Child Tracking System), the

Department’s new Statewide Automated Child Welfare Information System (SACWIS) system.

At that time, as a result of flaws in both the development and implementation of TFACTS, field

staff had difficulty entering and retrieving data; resource parents experienced delays in receiving

board payments; and the department leadership was hampered by the limited ability of the

Department’s Office of Information Technology (OIT) to produce timely and accurate data for

purposes of management and assessing case progress and performance.

The Department developed a plan to address the challenges identified by the two reports. At the

Court’s direction, the TAC conducted its own assessment of TFACTS to determine whether the

Department’s plan for improving and maintaining TFACTS was reasonably designed and

adequately resourced both to address the deficiencies in TFACTS and to ensure that the

Department’s automated information system was sufficiently functional to meet its internal

management needs and allow the Department to exit court jurisdiction within a reasonable time.

The TAC concluded that the Department’s plan was reasonable and since then the TAC has

provided regular updates to the parties and the Court detailing the Department’s progress in

implementing that plan.

Over the past four years, the Department has invested significant time and resources, not only to

address the specific problems identified in the earlier reports, but to ensure that its OIT has the

resources and technical expertise to meet its ongoing information technology (IT) needs. As

reflected in the Modified Settlement Agreement entered in April of 2015, this investment and the

improvements that resulted from it have led to the Department achieving maintenance on

TFACTS related requirements of the Settlement Agreement (Section X). As the Department

moves closer to successfully exiting court jurisdiction, the TAC has been asked to provide a brief

TFACTS update, explaining the TAC’s ongoing monitoring and validation activities with respect

to TFACTS and reflecting on the current experience of field staff with TFACTS functionality, on

recent developments in TFACTS reporting, and on prospects for sustaining performance beyond

exit.

B. Ongoing TAC Monitoring of TFACTS

In the time since all Section X provisions of the Settlement Agreement were designated as

maintenance, the TAC has continued to monitor TFACTS related matters. The TAC chair

periodically attends Management Advisory Committee (MAC) meetings and regularly reviews

minutes from those meetings, minutes that are posted to the Department’s Intranet website for

22

DCS TFACTS Assessment 23

Oversight for System Development Projects: A Review of TFACTS Implementation


30

distribution to all staff throughout the organization. In addition, TAC monitoring staff

participate regularly in System User Network conference calls (discussed below) and in monthly

TFACTS Reports Webinars. The monthly reports webinars, open to all Department staff,

provide a forum for communication with the field about newly developed reports, existing

reports undergoing modification, or reports about which the field has expressed confusion.

During the webinars, OIT customer service staff explain the functioning of the reports in detail,

and field staff have the opportunity to ask questions. In addition, TAC monitoring staff regularly

use TFACTS reports in the course of their monitoring and have found the data to be accurate.

Finally, TAC monitoring staff meet periodically with OIT customer service staff to review and

discuss the feedback received from the field (including HelpDesk Data and information provided

by the regional Field Customer Care Representatives).

TAC monitoring staff continue to monitor developments in TFACTS reporting, reviewing both

new Brian A. related reports (such as the new diligent search, EPSDT, and CANS tracking

reports discussed in the February 2016 Monitoring Report) and modifications of existing reports

(such as the CPS Referral Priority Response Report and the Sibling Visits Report). In

anticipation of exit, TAC monitoring staff have paid particular attention to the Department’s

internal processes for report development and validation, processes which have been well

designed and conscientiously implemented. Because of the particular interest in caseload

reporting and reporting related to child deaths, the TAC monitoring staff continue to closely

review the previously validated TFACTS reporting related to both of these areas, to provide

additional reassurance about the continued reliability of those reports. (Updated data related to

child deaths was presented and discussed in the February 2016 Monitoring Report. Updated

caseload data is included in an Appendix to this Supplemental Report, “Caseload and

Supervisory Workload Data.”)

C. Current Experience of Field Staff

Four years ago, case managers frequently complained about the challenges of using TFACTS in

their daily work. The system was slow and cumbersome; it often required multiple and

unnecessarily complicated mouse clicks to move through an electronic case file to enter or

retrieve data; and in some key areas, information was fragmented or required redundant data

entry. Case managers frequently complained of being “kicked out” of the system in the midst of

entering data or trying to retrieve information. Field staff had difficulty generating and printing

reports and forms from TFACTS. Many staff used computers that were old and slow, and

internet connections were insufficiently strong or fast. The system was plagued by frequent

problems with the Department’s servers.

Staff complained about the insufficiency of the TFACTS training they received, particularly the

lack of notice and orientation when changes were made in TFACTS. When new TFACTS

applications were rolled out, the change itself was often disruptive, and too often the new

application fell short of what the field had hoped for. All too frequently the release was

accompanied by glitches and defects that caused a new set of problems and required subsequent

fixes.


31

Most significantly, field staff perceived that their needs as system users were not being

sufficiently addressed by OIT and that their complaints were being largely ignored. As a result

of poor communication between OIT and the program staff in the field, case managers were

largely unaware of the significant infrastructure challenges that OIT was facing, challenges that

had to be addressed to stabilize the system, before significant improvements in the end user

experience would be possible.

As discussed in previous monitoring reports, the Department was able to successfully address all

of the infrastructure problems that had threatened the stability of TFACTS and undermined its

functionality.24

Upgrades in the TFACTS supporting infrastructure25

have not only improved

TFACTS performance and enhanced its capacity, but have given OIT the ability to deploy

TFACTS updates and enhancements into production without taking TFACTS offline, allowing

staff to continue to use TFACTS without interruption even as the new features are being

deployed. The previous TFACTS production infrastructure relied on six JBOSS application

servers that were insufficient to reliably support TFACTS. With the infrastructure upgrades, and

the migration of TFACTS to new servers housed in the south data center, TFACTS production

now runs on just four JBOSS servers, that are not only reliable but that have sufficient capacity

to maintain 50% resource availability during peak usage times.

Old computers have been replaced and more than 2,400 field staff are now benefiting from

tablets with specially designed TFACTS interfaces. Issues of connectivity and internet speed

have been largely addressed by these and other infrastructure improvements.

Most importantly, with the system stabilized and competently supported by a well-resourced and

highly skilled IT division, the bulk of the TFACTS related improvements are now being driven

by the needs and priorities of the program staff. This is apparent not only in the priorities

established and monitored by the Department’s leadership through the monthly MAC meetings

(discussed further below), but in the recently implemented “Solutions Development Triage,” a

weekly OIT meeting designed to ensure an appropriate review of and response to the complaints,

requests, and suggestions identified by field staff through the TFACTS Help Desk.

24

Initially there was considerable concern that the Department lacked the technical resources to modify those

aspects of TFACTS that had been designed with code that used OptimalJ. As discussed in previous monitoring

reports, the Office of Information Technology addressed that concern through strategic hires. The Department’s

considerable in-house expertise in both OptimalJ and TFACTS is reflected by the fact that since September 2013 all

necessary OptimalJ model changes have been done by DCS OIT staff without support or advice from outside

vendors. 25

This includes major upgrades in the JBOSS Application Server, Java, and Oracle.


32

In contrast to the situation four years ago, OIT now actively engages field staff in every stage of

the design, development, testing and roll out of TFACTS enhancements.26

As a result, the

TFACTS releases are now routinely experienced as welcomed improvements by well-oriented

field staff. Additional guardrails and drop-down boxes have helped support accurate and

complete data entry, and improved interfaces and strategic shortcuts have made file navigation

simpler and more efficient, including restructuring of the case manager’s “workload” screen

(showing the list of cases assigned to the worker). It is now the “home” screen viewed when the

user logs into TFACTS, eliminating the need for additional clicks to access it. Quick links have

been embedded into the list of cases, allowing case managers to go directly to the areas in the

case in which they work most often, such as the case recordings module, and a link has been

added to the workload page that lists important work items still remaining to be done for each

case.

TFACTS improvements deployed in 2015 that support better and more efficient front-line

practice while also providing improved tracking and reporting include:

Modifications of diligent search documentation and reporting, which simplified (and

therefore improved) data entry for case managers and captured diligent search activity in

ways that allow the kind of tracking and reporting presented in Section VIII.C.1 of the

February 2016 Monitoring Report.

Child Death/Near Death Workflow, which documents, tracks, and reports information

related to the deaths of children when there has been an allegation of neglect or abuse, or

the child is in the custody of the Department at the time of death.

Child Abuse Hotline Web Referral and Tracking, a web referral application that allows

users to complete a child abuse referral online. Once the referral form is submitted, the

information is populated to TFACTS by way of a web service, and an intake ID is

returned to the user, allowing the user to track the progress of the investigation resulting

from the referral.

Mandatory Race, an enhancement that requires documentation of Race and Hispanic

Origin for children/youth served by the Department, as well as for persons approved as

Resource Parents.

FAST 2.0 Enhancement, which improved the Family Advocacy and Support Tool

(FAST) assessment within TFACTS, eliminating the need to use other tools.

26

In a report filed with the Court three years ago, the TAC observed that the Department’s biggest remaining

challenges related to TFACTS functionality and reporting were not so much technological challenges, but rather

challenges in moving from a “siloed” and “chain of command” approach for identifying and responding to the IT

needs of the field to a “teaming” approach. As the TAC wrote, “Many of the problems with TFACTS, whether with

the design of a particular TFACTS field or with the quality/utility/accuracy of TFACTS reports, are the result of

miscommunication and misunderstanding. Sometimes that is a misunderstanding by the IT staff of the realities of

the practice that the application is intended to support, or of the purpose a report is supposed to serve, or of the key

questions that the report is intended to answer. Sometimes it is the result of well-intentioned, but insufficiently

thought out instructions given by program staff to IT staff. The IT staff need help gaining a good understanding of

the field’s needs, helping the field understand the options available to meet those needs, and helping the field

prioritize those needs so they can be appropriately sequenced and resourced. This requires a structure that facilitates

productive discussion and informed decision making about IT priorities.”


33

The Department has also responded to concerns about the adequacy of TFACTS training for

field staff. In addition to the TFACTS training conducted as part of pre-service training, the

Department now holds monthly System User Network meetings (run by TFACTS Field

Customer Care Representatives, or FCCRs, in the region and open to all Department staff),

which provide a forum to respond to TFACTS related feedback from the regions, to explain

changes in TFACTS that have been made in response to policy changes or federal requirements,

and to alert the regions to upcoming TFACTS builds. With respect to data that are used for

reporting purposes or to respond to certain federal requirements, the Department uses the System

User Network meetings to both help staff understand how to enter the data and to help staff

understand why timely and accurate entry of that data is so important. And a variety of TFACTS

reports are generated to help case managers and supervisors track timeliness and accuracy of data

entry and respond appropriately to data entry errors or omissions.27

D. Current TFACTS Reporting

As discussed in the April 2015 Supplement to the January 2015 Monitoring Report, with the

successful release of the TFACTS Case Assignment enhancement in December 2014 and the

improved caseload tracking and reporting that this enhancement made possible, the Department

had available the basic range of aggregate reporting required for responsibly running a child

welfare system. Since that time, the Department has continued to refine and add to its regular

reporting, including producing additional tracking reports to support and monitor performance

related to three of the remaining substantive Settlement provisions not yet designated

maintenance: diligent search practice (VIII.C.1), timely completion of CANS and EPSDT

assessments (VI.B), and timely convening of quarterly review CFTMs (VII.K).

Particularly noteworthy has been the dramatic streamlining of the approval process and timeline

for approval and development of new reports or modifications to existing reports. In the past, an

overly bureaucratic and compartmentalized approach to report approval and production resulted

in bottlenecks and backlogs in responding to report requests, and impeded, rather than

encouraged, communication between report developers and program staff during the report

development process, communication that is so important to ensuring that the report meets the

needs of the field. Development was driven by a “reports backlog” reflecting all outstanding

requests that included report requests that were years old, some of which no longer had any

relevance for current practice.

The former process has been discontinued and replaced with a more strategic approach to report

prioritization and development. Requests for new reports are sent directly to a representative of

the MAC and an OIT liaison who work with the requestor to identify the scope and impact of the

request. Report requests are then prioritized, taking into account the amount of time required to

develop the report; the number of users who will benefit from its implementation; any impact on

litigation, funding, or legislative mandates; and whether a comparable tool exists to meet

business needs. When a report is approved for development, OIT staff work directly with

program staff with relevant expertise to ensure that the final product is a valuable, effective tool

27

Among others, these include the Diligent Search and CANS/EPSDT tracking discussed in the February 2016

Monitoring Report and the timeliness of permanency planning discussed in the July 2015 Monitoring Report.


34

for staff. Because of the streamlined approach to managing requests for new reporting or report

modifications, the Department is able to strategically deploy resources by combining efforts that

implicate similar or overlapping data.

One of the most frustrating aspects of the former system for staff was the lack of communication

about what projects would be undertaken and what the timeline for completion would look like.

In order to address this issue, a new tool is being utilized to track the progress of a report request

from submission through deployment. Authorized users can see where reports have been

prioritized, what stage of development reports are in, who is assigned to each phase of work, and

any notes from developers about challenges as they arise. This tool has eliminated much of the

guesswork about how development resources are being directed by providing program staff with

insight into the development process.

E. Sustainability

The improvements in TFACTS functionality and reporting reflect the effectiveness of the MAC

in providing ongoing oversight, direction, and support to OIT. The MAC, which is chaired by

the DCS Commissioner, and includes all Deputy Commissioners, two regional administrators

and other field and program representatives, is responsible for:

providing IT with strategic decisions and direction;

establishing IT priorities;

guiding IT planning;

participating in IT project oversight;

providing a forum for all DCS programmatic areas on issues related to IT; and

ensuring that IT has the resources to meet its responsibilities.

Over the past three years, the MAC has become an extremely effective forum for IT related

decision making. The current OIT Director does an excellent job of ensuring that the leadership

team has the information they need to understand the relevant opportunities and challenges and

to make knowledgeable decisions about priorities and options. The OIT Director has also

invested time and effort in understanding the work of program staff so that he and his staff find

better ways to support that work.

The MAC meetings, which had been originally scheduled on a quarterly basis, now occur

monthly and are among the most well-organized, productive and informative meetings that the

TAC has been privileged to observe. All of the key program, fiscal, and IT decision-makers

attend and actively participate, allowing issues to be fully discussed and decisions to be made

based on those discussions.

In the TAC’s view, the MAC structure and process ensures that the Department’s IT functions

will continue to receive the direction, support, and attention that they need from the

Department’s leadership. The TAC is confident that this will ensure that the Department will

continue to have a well-functioning and well-maintained IT system.


1

APPENDIX VII.B

For ease of the reference, the entire subsection below is excerpted from the February 2016

Monitoring Report with the supplemental language requested by the parties added in italics in the

paragraph following Table 7.1.

A. Participation by Children and Families in the CFTM Process

The table below reflects the frequency with which older children (youth age 12 and older),

parents, and family and fictive kin attended Child and Family Team Meetings convened in their

cases. For each CFTM type, the table presents two percentages.

The first percentage, presented in bold type, is the percentage reflected by the results of the CFT

Process Review. The percentages of older youth participating in CFTMs reflect the experiences

of the 40 youth in the review sample who were 12 years of age or older during the review period.

For purposes of calculating the percentage of parents participating in CFTMs for the 92 children

in the sample, parents whose parental rights had been terminated prior to the CFTM and parents

who were deceased were excluded.28

In the sample, there were four mothers (two at the time of

the Initial and Initial Permanency Planning CFTMs, and two additional at Placement Stability

CFTMs) and one father (at the time of the Placement Stability CFTM) whose parental rights had

been terminated, and there were three mothers and three fathers who were deceased.29

The second percentage (italicized and indicated in parentheses below the CFT Process Review

data) is the percentage reflected by the aggregate CFTM reporting for 2014.30

As discussed in

previous monitoring reports, the TAC has found that the aggregate CFTM reporting generally

understates the Department’s performance31

and therefore the CFT Process Review data would

be expected to show higher levels of CFTM member participation than the CFTM aggregate

reporting, and that is in fact reflected in Table 7.1 below.

28

The language “mothers who would have been expected to have participated” and “fathers who would have been

expected to have participated” reflects this exclusion. 29

In addition, there was one mother who was alleged to have committed severe abuse; and there was one case in

which children had been adopted from Haiti and there was no mention of them having had an adoptive father. 30

For all CFTMs other than the Discharge CFTM, the percentage is based on four quarterly CFTM reports for

calendar year 2014. Because of an oversight, the Office of Information Technology did not produce a Discharge

CFTM aggregate participant attendance report for the first quarter of 2014. For this reason, the CFTM aggregate

reporting percentages for Discharge CFTM participation is based on three quarterly reports rather than four. 31

See July 2015 Monitoring Report, footnote 341 at p. 208.


2

Table 7.1: Child and Family Participation in CFTMs

Initial CFTM

Initial Permanency

Planning CFTM Placement

Stability CFTM Discharge

Planning CFTM

Youth 12 and Older

84%32 (70%)

100%33 (76%)

75%34 (76%)

95%35 (86%)

Mother 81%36 (66%)

83%37 (65%)

66%38 (40%)

57%39 (42%)

Father 37%40 (29%)

38%41 (31%)

23%42 (15%)

40%43 (16%)

Kin 63%44 (42%)

51% (33%)

36% (25%)

45% (27%)

Source: May 2015 Child and Family Team Process Review and Child and Family Team Meeting (CFTM) Summary reports for the four quarters of 2014.

A parent or a present or former relative caregiver was present at 82 (92%) of the 89 Initial

CFTMs and at 82 (89%) of the 92 Initial Permanency Plan CFTMs. In 88 (96%) of the cases, a

parent or a present or former relative caregiver was present for at least one of those CFTMs. A

parent or a present or former relative caregiver was present at 55 (68%) of the 81 Placement

Stability CFTMs and 26 (84%) of the 31 Discharge Planning CFTMs.

32

Initial CFTMs were held for 38 youth 12 and older: 27 (71%) were physically present and five (13%) participated

by telephone. 33

Initial Permanency Planning CFTMs were held for 40 youth 12 and older: 32 (80%) were physically present and

eight (20%) participated by telephone. 34

Placement Stability CFTMs were held for 36 youth 12 and older: 23 (64%) were physically present and four

(11%) participated by telephone. 35

Discharge CFTMs were held for 20 youth 12 and older: 18 (90%) were physically present and one (5%)

participated by phone. 36

Mothers would have been expected to have participated in 84 of the 89 Initial CFTMs held. The 81% attendance

number includes 59 (70%) who were physically present and nine (11%) who participated by phone. 37

Mothers would have been expected to have participated in 87 of the 92 Initial Permanency Plan CFTMs held. The

83% attendance figure includes 62 (71%) who were physically present and 10 (12%) who participated by phone. 38

There were 81 Placement Stability CFTMs held in the 92 cases reviewed (in some cases, one child had a number

of Placement Stability CFTMs during the review period). Mothers would have been expected to participate in 70 of

those CFTMs. The 66% attendance figure includes 36 (52%) who were physically present and 10 (14%) who

participated by phone. 39

Mothers would have been expected to have participated in 28 of the 31 Discharge Planning CFTMs held. The

57% attendance figure includes 15 (54%) who were physically present and one (3%) who participated by phone. 40

Fathers would have been expected to have participated in 86 Initial CFTMs. Fathers participated in 32 (37%) of

those CFTMs: 26 (30%) were physically present and six (7%) participated by telephone. 41

Fathers would have been expected to have participated in 89 Initial Permanency Planning CFTMs. Fathers

participated in 34 (38%): 28 (31%) were physically present and six (7%) participated by telephone. 42

Fathers would have been expected to have participated in 73 Placement Stability CFTMs. Fathers participated in

17 (23%) of those CFTMs: 14 (19%) were physically present and 3 (4%) participated by telephone. 43

Fathers would have been expected to have participated in 30 Discharge CFTMs. Fathers participated in 12 (40%)

of those CFTMs: 11 (37%) were physically present and one (3%) participated by telephone. 44

At least one kin (relative or friend) was present at 56 (63%) of the Initial CFTMs held, 47 (51%) of the Initial

Permanency Plan CFTMs, 29 (36%) of the Placement Stability CFTMs, and 14 (45%) of the Discharge Planning

CFTMs.


1

Appendix VIII.C.1

The following screenshots show the dropdown boxes available in TFACTS to indicate the

specific type of diligent search activity completed.


1

APPENDIX XVI.A

This appendix presents tables containing the numerical values from which Figures 16.1 and 16.2

were created.


Table 16.1: Moves Per 100 Days in Care

Cohort Year

State 2010 2011 2012 2013 2014

1 0.23 0.22 0.23 0.23 0.23

2 0.25 0.24 0.24 0.27 0.25

3 0.24 0.24 0.24 0.25 0.24

4 0.24 0.20 0.20 0.22 0.24

5 0.31 0.32 0.33 0.38 0.31

6 0.28 0.30 0.30 0.35 0.28

7 0.31 0.33 0.31 0.36 0.31

8 0.25 0.27 0.26 0.30 0.25

9 0.33 0.35 0.34 0.34 0.33

A 0.26 0.27 0.30 0.26 0.26

B 0.21 0.19 0.22 0.27 0.21

C 0.41 0.43 0.43 0.56 0.41

D 0.27 0.27 0.29 0.32 0.27

E 0.26 0.27 0.29 0.27 0.26

F 0.39 0.40 0.39 0.44 0.39

G 0.25 0.23 0.22 0.23 0.25

TN 0.27 0.28 0.28 0.33 0.27

H 0.33 0.33 0.33 0.33 0.33

I 0.24 0.25 0.26 0.34 0.24

19 States 0.28 0.28 0.28 0.31 0.28


2


Table 16.2: Reentry within 12 Months after Permanency Exit

Cohort Year

State 2010 2011 2012 2013 2014

1 13% 13% 12% 11% 9%

2 11% 10% 10% 9% 6%

3 15% 14% 14% 12% 5%

4 9% 11% 12% 11% 4%

5 9% 8% 2% 6% 4%

6 13% 15% 13% 11% 10%

7 9% 8% 8% 9% 5%

8 17% 19% 21% 17% 10%

9 22% 21% 22% 21% 13%

A 18% 18% 17% 14% 6%

B 21% 14% 19% 22% 17%

C 14% 15% 14% 13% 9%

D 15% 15% 16% 14% 10%

E 12% 10% 12% 12% 3%

F 12% 12% 9% 10% 6%

G 21% 17% 18% 19% 15%

TN 14% 12% 12% 12% 8%

H 10% 10% 10% 8% 6%

I 14% 15% 13% 15% 8%

19 States 13% 12% 12% 11% 7%


1

APPENDIX: CASELOAD AND SUPERVISORY WORKLOAD DATA

The July 2015 Monitoring Report provided caseload and supervisory workload data for the

period from July 2014 through April 2015. This appendix provides caseload and supervisory

workload data for the nine-month period from May 2015 through February 2016. All caseload

and supervisory workload data is based on TFACTS reporting that the TAC monitoring staff

have validated and continue to review and spot check.45

A. DCS Case Manager Caseloads

Table 1 below presents the percentage of case managers carrying at least one Brian A. case

whose caseloads were within the caseload limits established by the Settlement Agreement,

statewide and by region, as of the end of each month.

45

TAC monitoring staff reviewed each month’s summary reports for consistency with previous months’ reports

(looking for any changes that would warrant further investigation, such as a significant increase or decrease in the

total number of case managers or in the compliance percentage) and spot-checked the data for a few case managers

and supervisors through comparison to detail reports and to TFACTS. TAC monitoring staff also verified the

supervisory structures for every Brian A. team for four reports (August 2015, November 2015, January 2016, and

February 2016).


2

Table 1: Of Case Managers Carrying at Least One Brian A. Case,

Percentage Meeting Caseload Requirements as of the Last Day of Each Month

Region May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Davidson 97% 100% 100% 100% 100% 100% 100% 100% 97% 100%

East 100% 97% 97% 100% 97% 97% 94% 91% 97% 100%

Knox 100% 100% 98% 100% 98% 100% 98% 100% 100% 100%

Mid Cumberland 95% 89% 93% 87% 88% 89% 93% 98% 96% 94%

Northeast 94% 93% 96% 90% 92% 98% 94% 91% 94% 96%

Northwest 90% 86% 87% 84% 88% 91% 86% 92% 94% 96%

Shelby 100% 100% 98% 100% 95% 95% 90% 90% 93% 95%

Smoky Mountain 93% 96% 96% 96% 100% 98% 98% 98% 98% 96%

South Central 100% 100% 100% 100% 100% 97% 97% 97% 97% 97%

Southwest 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Tennessee Valley 98% 98% 96% 93% 96% 98% 98% 96% 93% 94%

Upper Cumberland 94% 94% 89% 83% 83% 92% 91% 94% 89% 90%

Statewide

97% 96% 96% 94% 94% 96% 94% 96% 96% 96%

(n=495) (n=488) (n=506) (n=512) (n=517) (n=507) (n=501) (n=518) (n=513) (n=525) Source: TFACTS Caseload Summary Reports for May 2015 through February 2016.


3

Figure 1 below presents, for case managers who had at least one Brian A. case on their caseloads

(without regard for case manager job classification) on February 29, 2016, the percentage of case

managers whose caseloads fell within each category (0-15 cases, 16-20 cases, 21-25 cases, and

more than 25 cases).46

Source: TFACTS Brian A. Caseload Threshold Compliance Report as of February 29, 2016.

As of February 29, 2016, the breakdown of compliance with the Brian A. caseload standards by

case manager position is as follows:

Case Manager 1: 91% (85/93);

Case Manager 2: 99% (383/387);

Case Manager 3: 91% (38/42); and

Team Leader: 0% (0/3)—three team leaders appear on the report as having a small

number of cases assigned, but these assignments reflect the assignment process in

TFACTS, whereby the case is briefly assigned to the team leader’s tree in the process of

transferring it to the case manager, and are not actual assignments to the team leader to

work the case.

46

For reasons having to do with the nature of the analysis, the data in Figure 1 do not account for the different

caseload caps of case manager 1s, case manager 2s, and case managers 3s in the way that Table 1 above does.

32

32

33

32

28

24

47

32

10

20

25

20

5

6

16

17

20

9

15

23

20

4

24

27

0

0

0

0

0

0

0

0

0

0

0

1

0

0

0

0

0

0

0

1

0

0

0

2

0% 20% 40% 60% 80% 100%

Davidson

East Tennessee

Knox

Mid-Cumberland

Northeast

Northwest

Shelby

Smoky Mountain

South Central

Southwest

Tennessee Valley

Upper Cumberland

Figure 1: Percentage of Case Managers Carrying at Least One Brian A. Case by Caseload Size as of February 29, 2016, by Region

1-15 cases 16-20 cases 21-25 cases More than 25 cases


4

B. DCS Supervisor Workloads

Table 2 below shows the percentage of teams in each region that were in compliance with the

supervisory workloads based on the TFACTS Supervisory Caseload Compliance Summaries.


5

Table 2: Percentage of Supervisory Workloads Meeting Settlement Agreement Requirements for All Teams with at Least One Brian A. Case

May-15 Jun-15 Jul-15 Aug-15 Sep-15 Oct-15 Nov-15 Dec-15 Jan-16 Feb-16

Davidson 100% 100% 89% 80% 100% 90% 89% 88% 90% 90%

East 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Knox 100% 100% 100% 100% 93% 100% 100% 100% 100% 100%

Mid Cumberland

94% 100% 88% 93% 94% 100% 100% 100% 100% 100%

Northeast 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Northwest 88% 88% 88% 82% 92% 92% 100% 92% 92% 90%

Shelby 100% 94% 94% 95% 95% 90% 90% 95% 90% 95%

Smoky Mountain

100% 100% 100% 100% 92% 92% 100% 100% 100% 100%

South Central 100% 89% 100% 100% 100% 100% 100% 100% 100% 100%

Southwest 100% 100% 100% 100% 100% 100% 100% 100% 100% 100%

Tennessee Valley

93% 92% 100% 100% 100% 100% 100% 100% 100% 100%

Upper Cumberland

100% 87% 92% 100% 100% 92% 100% 100% 100% 93%

Statewide

98% (n=157)

96%

(n=155)

96%

(n=150)

96%

(n=155)

97%

(n=157)

96%

(n=155)

98%

(n=155)

98%

(n=154)

97%

(n=159)

97%

(n=159) Source: TFACTS Supervisory Caseload Compliance Summaries as of the end of each month, May 2015 through February 2016.


Documents

THE TECHNICAL ASSISTANCE COMMITTEE IN THE CASE OF · THE TECHNICAL ASSISTANCE COMMITTEE IN THE CASE OF BRIAN A. v. HASLAM SUPPLEMENT TO THE FEBRUARY 8, 2016 MONITORING REPORT April